Newly released results of two important studies add to the
accumulation of evidence that chronic hostility and chronic depression
are major risk factors in heart disease. For many patients, it may be
as important to learn and practice skills for managing these emotional
states as it is to quit smoking, manage cholesterol, and exercise.

Hostility linked to need for repeat angioplasty.
Do you speak rapidly, forcefully, loudly? Do you frequently make
cynical, surly or rude remarks? Do you often interrupt others,
disagree forcefully and argue?

If you answered "yes" to these questions, your level of hostility may
be hazardous to your heart. The most recent findings linking hostility
and coronary heart disease come from a study of patients undergoing
balloon angioplasty. In this increasingly popular treatment for
certain types of blockages, a thin catheter is used to open the
coronary artery and a balloon inflated to permit more blood to flow to
the heart muscle. More than a third of people undergoing angioplasty
must have a second procedure within six months to reopen the blocked
artery.

Why? Part of the answer may lie in the patient's temper. Behavioral
medicine specialist Mark Goodman observed that many of the heart
patients referred to him for stress reduction training required repeat
angioplasties and that these patients tended to be very angry,
hostile, and difficult to deal with. To test for a connection, he
assessed 41 angioplasty patients for Type A behavior by observing
speech patterns and responses to mild provocation in an interview. The
coronary arteries of patients classified as having high potential for
hostility tended to block off again. These patients were more than
twice as likely to undergo a repeat angioplasty than the calmer
patients.

The reasons for the increased rate of artery blockage is not known. However, other studies of hostile type A's show they have higher levels of stress hormones in their blood which make their vessels more likely to constrict and may accelerate the formation of new blockages.

On the basis of these findings, the authors of the study have
developed a behavior modification program as part of rehabilitation
for angioplasty patients. The goal is to help patients reduce their
hostility and thereby reduce the progression of artery blockage and
need for repeat procedures. Also on the horizon are medications to
block hostility or at least lessen its harmful effects on the heart.
Chronic Depression Linked to First Heart Attack

A growing body of evidence suggests that managing depression is important in dealing with a number of serious health conditions - especially for women. Health professionals should try to help patients identify and look for the root cause of depression as a possible way to prevent heart attack.
This strategy was clearly supported by previous studies connecting depression and the risk of recurrent heart attack. Now, the results of a 27-year study released this summer establish a clear link between depression and the risk of having a heart attack in the first place.

The study followed 730 men and women in Glostrup, Denmark, all born in 1914. Subjects were tested in 1964 and again in 1974 for physical and psychological symptoms of depression. Those with a high measure of depressive symptoms had a 70% increased risk of heart attack. In fact, those who had signs of depression at the beginning of the study were 60% more likely to die early from any cause. The implications are even greater for women who, research shows, are much more likely than men to experience depression.

Exactly how depression triggers disease is not known. The researchers speculate that depressed people may be more likely to engage in self-destructive, high-risk behavior such as smoking. Smoking was more prevalent among the depressed women in this study. Another factor may be that depression stimulates the sympathetic nerves which increase heart rate, constrict blood vessels and elevate blood pressure.

Whatever the causes, it is clear that learning to recognize and then manage the symptoms of depression with medications and/or cognitive therapy, exercise, and psychotherapy is important for many. Taking steps to reduce hostility and depression may help many of us avoid the tragedy and distress of heart attacks. It may also go a long way to relieve the enormous financial burden of this chronic disease on our struggling health care system.

David S. Sobel, M.D., M.P.H., is a practicing physician in adult medicine and Medical Director of Patient Education and Health Promotion for Kaiser Permanente Northern California. He is physician lead for the......more

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